What does your insurance cover when it comes to plastic surgery?

With over 1500 plastic and reconstructive surgical procedures in the Medicare schedule, you really need to be certain on what you are covered for.

For Medicare, the decision to cover any plastic surgery procedure has always revolved around whether it is considered essential for quality of life or not. In other words; is it reconstructive surgery, or purely aesthetic? Medicare tends to cover most reconstructive surgery but not purely appearance-orientated surgeries.

If you are thinking about having plastic surgery, there are a few things you need to consider before booking a procedure.

What is the difference?

Medicare tends to cover most reconstructive surgery, even if only performed in the public system which may involve long waits. However, many insurance policies have tight restrictions or exclusions when it comes to plastic surgery.

There has always been some misperception and overlapping between reconstructive surgery and cosmetic surgery. Plastic surgery can refer to both of these, but they are very different things.

Reconstructive plastic surgery refers to a procedure performed to resolve defects, burns and scars, physical effects from disease or trauma, or to restore normal bodily function. The majority of these are deemed necessary to give the patient quality of life. Cosmetic surgery, on the other hand, is an operation performed where no previous medical issue exists so the sole reason is to enhance a patient’s appearance. This is where problems arise; what one doctor recognises as a problem may be deemed purely cosmetic by the insurance company.

Private Health

There have been reports that certain private health companies have rejected claims for procedures even when these are included in the Medicare list of eligible surgeries. This has left patients in a difficult situation; either pay the total amount directly and fight for compensation later, or consider the hard decision to postpone or even cancel their surgery. According to the insurance companies, they have had to introduce eligibility criteria to ensure claims are genuine as they allegedly have received a growing number of incorrect and false claims.

The Australian Society of Plastic Surgeons (ASPS) raised concerns over these changes taking place within the insurance industry. While ASPS agree that aesthetic services shouldn’t have a Medicare number, they do object the fact that some health funds seem to have taken it upon themselves to reject the surgeon’s decision and deem the procedure cosmetic rather than medically necessary. There is also the worry of legitimate claims not being approved because insurance companies have gained more decision-making power than medical professional and doctors.

With this in mind, it is not strange that patients have become hesitant when it comes to private health insurance. Fears have also been raised about unsuccessful claimants being driven towards unaccredited facilities and to cheap surgeons overseas. ASPS has had a number of meetings with the relevant regulatory authorities, with which they are also cooperating to find a solution, and hope to give patients clarity about their insurance cover.

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